News & Analysis as of

New Clarifications Affect Physician and Hospital Medicare Part B Billing for Services Provided by Nursing and Other Staff...

CMS recently released rules changing the requirements for Medicare coverage of services furnished incident to a physician’s, NP’s, or PA’s services. Howard Sollins, Donna Senft and Susan Turner explain the effect of the...more

Congress Sends Mixed Messages to Health Care Providers

Recent federal health care legislation sent mixed signals to health care providers. Pursuant to HR 4302, signed by President Obama on April 2, planned Medicare reimbursement cuts of 24 percent and the implementation of a...more

Anatomy of an Independent Primary Care ACO, Part I

While concepts and theories can go a long way, sometimes the best way to understand something is through a concrete example. So, from time to time, ACO Insider will check in on a new accountable care organization composed of...more

News from the Health Law Gurus™: July 2014

Survey of ACA Navigators Finds 10.6 Million People Sought Enrollment Help — In a survey released this week, the Kaiser Family Foundation (“Kaiser”) estimates that approximately 10.6 million people received assistance...more

OIG Report Recommends Increased Scrutiny of Over 1000 Laboratories With Questionable Billing for Medicare Part B Clinical...

According to a recently released report by the HHS Office of Inspector General (OIG), over 1,000 labs had unusually high billing for Medicare Part B Clinical Laboratory Services for dates of service in 2010. Increased...more

CMS Proposes Changes to Sunshine Act Reporting

Drug and device manufacturers breathing a sigh of relief after completing their 2013 data submissions under the Physician Payment Sunshine Act (the “Sunshine Act’) must now contend with four proposed changes to the Sunshine...more

OIG: Medicare Inappropriately Paid for 2010 E/M Services Claims - Physicians should expect higher scrutiny on Medicare claims...

Inspector General Daniel R. Levinson with the Office of the Inspector General (“OIG”) recently issued a startling report explaining that Medicare inappropriately paid $6.7 billion for claims for E/M Services in 2010. These...more

Risk Taking in the Provider World: Is a Knox-Keene Plan a Good Strategic Move For You?

Reimbursement for health care services in California continues its shift toward capitation, resulting in health care providers increasingly forming their own health plans under the Knox Keene Health Care Service Plan Act (the...more

Cloudy Skies Ahead for Providers? CMS’ Release of Medicare Billing Data Combined with Physician Payment Sunshine Act Data May...

In February 2013, we reported (on our Healthcare Law Blog) that the Centers for Medicare and Medicaid Services (CMS) announced the final rule for the Physician Payments Sunshine Act. In the interest of providing more...more

AMA To Recommend Physicians Be Paid For End-Of-Life Planning

Brace yourself for a reprise of the death panel debate of 2009. The AMA will soon formally recommend to CMS that physicians be paid—or “reimbursed” in health care-speak—for talking with Medicare patients and their families...more

Quantifying and addressing improper payments for Medicare evaluation and management services

A review of Medicare Part B claims for evaluation and management (E/M) services conducted by the Office of the Inspector General (OIG) has found that the program paid $6.7 billion in improper payments in 2010. This figure...more

How Are Your Physicians Compensated? Stark Law + False Claims Act = Halifax Paying $85 Million

On March 10, 2014, just days before trial, Halifax Hospital Medical Center and Halifax Staffing, Inc. (collectively “Halifax”) entered into an $85 million settlement with the U.S. Department of Justice resolving allegations...more

Recent OIG Report Underscores Need for Home Health Agencies and Physicians to Comply With Medicare’s Face-to-Face Documentation...

Medicare overpaid the home health industry $2 billion between January 2011 and December 2012, according to a recent report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG). The OIG’s...more

Transgender Woman Seeks Coverage Under ACA

A transgender woman recently filed a complaint in the U.S. District Court for the Central District of Illinois against her primary care physician, as well as the not-for-profit health-care clinic with which her physician is...more

Health Law Wire: Physician Medicare Revalidation Notice

On January 29, 2014, the National Government Services, Inc. announced that it would begin mailing out revalidation notices (“Notice”) to physicians enrolled in the Medicare program sometime in the next (12) months. Physicians...more

CMS Advised to Follow Private Sector Practices to Improve Physician Feedback Reports

On March 26, 2014, the Government Accountability Office (GAO) released its report regarding the private sector’s physician feedback reporting practices and how implementation of such practices could improve CMS’s own reports...more

When It Comes to Medicare Payment, Physicians Have Choices

Health care providers can choose to enroll in, participate in, or opt out of Medicare, but… - Not everyone can choose equally and their choices will net direct outcomes in their practice income. Medicare jargon can be...more

CMS authorizes contractors to deny ‘related’ claims of physicians who are not undergoing review

The Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services recently issued Transmittal 505 modifying Section 3.2.3 of the Medicare Program Integrity Manual. CMS employs a variety of...more

Joint SGR Repeal Bill Agreed Upon, Moving to Full Congress

New joint legislation to repeal Medicare’s failed SGR formula is advancing to both chambers of Congress following an agreement announced Thursday by the three committees that put forth repeal bills earlier this...more

Funding Offsets Proposed for Physician Payment Overhaul

Congressional lawmakers are currently reviewing 65 potential funding offsets for legislation that would overhaul the Medicare physician payment system. In its present form, Medicare’s sustainable growth rate (SGR) formula...more

Also in the News

President Obama Signs Pathway for SGR Reform Act of 2013 – On December 26, 2013, President Obama signed the Pathway for SGR Reform Act of 2013 (the “Act”), preventing the scheduled payment reduction for...more

SGR-Driven Payment Reduction Postponed Again

As part of the Balanced Budget Act of 1997 (BBA), Congress enacted a number of payment reforms designed to curb the growth of expenditures under Medicare Part B. One of the more notable of those provisions was the Sustainable...more

Congress Passes 3 Month SGR Reprieve: .5% Medicare Physician Increase

The AMA Wire reports action on the Medicare Physician Fee Schedule. The payment increase staves off a 24 percent cut required by the failed SGR formula and buys three months for Congress to complete its work on SGR repeal...more

Judge Issues Preliminary Injunction Barring UnitedHealthcare from Terminating Certain Physicians From Medicare Advantage Plans

The United States District Court for the District of Connecticut recently granted Fairfield County Medical Association’s and Hartford County Medical Association’s (collectively, the “Associations”) motion for a preliminary...more

CMS Announces Plans to Modernize and Update the Clinical Laboratory Fee Schedule

On November 27, 2013, Centers for Medicare & Medicaid Services posted the final 2014 Medicare physician fee schedule and, in it, announced plans to change how and how much Medicare pays for clinical diagnostic laboratory...more

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